Nurses help bring TAVR program to New York Methodist

Thanks to newly trained interdisciplinary staff at New York Methodist Hospital in Brooklyn, patients with aortic stenosis who are too sick or frail to withstand open heart surgery that could boost their quality of life have another option.

The treatment is called transcatheter aortic valve replacement and is approved to treat only the sickest patients with life-threatening aortic stenosis who cannot withstand traditional valve replacement surgery.

With TAVR, also known as TAVI or transcatheter aortic valve implantation, instead of opening the chest, surgeons access blood vessels through a nickel-sized incision in the thigh. The surgical team then uses real-time imaging to guide the prosthetic valve up the blood vessels, into the heart, and deploy it in place of the old aortic valve.

The procedure is performed in NYM’s refurbished catheterization lab by clinicians from NYM and NewYork-Presbyterian/Weill Cornell Medical Center. Only about 50,000 TAVRs have been performed worldwide since the first procedure in 2002, according to the National Institutes of Health.

Rebecca Flood, RN

Nurses trained offsiteNancy Rizzuto, RN, CCRN, associate director of nursing at NYM, oversees the CTICU and cardiac cath labs and was a key player in bringing the program to the hospital. Her 30 years of cardiac surgery experience helped her lead the effort. Starting two years ago, when the idea was first proposed, Rizzuto did the research on how to start the program and then initiated nursing staff training.

That process, she said, involved scheduling nurses to shuttle to and from training at both Cornell and Columbia University while ensuring the staffing levels and level of care expected for open heart and complicated thoracic cases at NYM didn’t suffer.TAVR involves three basic roles for nurses, Rizzuto said. Scrub nurses maintain a sterile field in the OR and pass sterile instruments. Besides the scrub nurse and circulating nurse, a third RN in the room is trained in pacing, an integral part of the procedure, she said.

“The heart rate has to be accelerated so there’s no blood flow at the time of the deployment of the valve because it could dislodge the placement,” Rizzuto said. Most important for hospitals looking to start such a program is an unfailing commitment from leadership, she said.

“If you do not have the support of leadership, it will fail,” she said. “I was lucky to have that support.”

Rewards in progressResults from the procedure can be dramatic. “These are patients who can barely walk into the building and their breathing is so labored and they’re basically chair-bound,” she said. “When they come back weeks later, it’s so emotional. You’ve actually given them a better quality of life.”

Rebecca Flood, RN, senior vice president for nursing, put her faith in Rizzuto to lead the training and was not disappointed.

“I have to say she did it beautifully,” Flood said. “There was no blip in care … nor was there any problem in training the nurses.”

Flood said the advice she would offer to nurses at institutions implementing TAVR is to realize this technique will not be used very often, at least until it is approved for more patients.

“You gear up for this, what you think in your mind is going to be this large onslaught of patients when in fact it’s really a small group (of about one patient a week),” she said. “That’s not because of referral patterns or expertise.

“That’s because this treatment is only approved for a very small portion of the population.”

The challenge, she said, is to bring the excitement and education to an infrequently used procedure.